Initial Treatment of Pelvis Fractures. COA Monterey June 1, 2014 Michael Bellino

Transcription

1 Initial Treatment of Pelvis Fractures COA Monterey June 1, 2014 Michael Bellino

2 Key Points Three categories of pelvis fractures Get involved Recognize injury patterns that require immediate treatment

3 Elderly Low Energy Complete sacral fx with bilateral rami fx displaced 68% Incomplete sacral fx with ispilateral rami injury had no displacement Bruce, et al, JOT 2011

4 Non Structural Ring Disruption

5 Structural Ring Disruption

6 High Energy Injury High Rate Associated Injury Life Threatening Pelvic Ring Injuries Mortality 6-12% < 4 hours injury

7 Associated Injury Hemorrhage Neurologic Urologic Gynecologic Gastrointestinal Soft Tissue

8 Associated Injury Hemorrhage Neurologic Urologic Gynecologic Gastrointestinal Soft Tissue

9 Physical Exam - Skin Perineal Lacerations Scrotal/Labial Swelling Flank Ecchymosis Abrasions/crush Morel-Lavalle degloving

10 Physical Exam - Skin Perineal Lacerations Scrotal/Labial Swelling Flank Ecchymosis Abrasions/crush Morel-Lavalle degloving

11 Physical Exam - Provocative AP Compression Lateral Compression One Positive Exam Only!

12 Provides the majority of information Guides further studies Essential in the initial evaluation of the trauma patient AP Pelvis

13 Provides the majority of information Guides further studies Essential in the initial evaluation of the trauma patient AP Pelvis

14 S1 body, sacral ala Anterior /posterior displacement Anterior ring morphology Horizontal plane rotation Inlet

15 Sacral morphology Sacral foramina SI joint Cranial displacement Outlet

16 Conventional Plain radiographs Volume Rendered

17 CT Scan Conformation of plain film assessment Detects posterior ring injury missed on plain film Essential for pre-operative planning reduction and fixation

18 CT Surfaced Rendered Beware loss of subtle detail-computer averaging Utility as an overview, final confirmation

19 Mechanism of Injury Young-Burgess Anterior-Posterior Compression Lateral Compression Vertical Shear Combined Mechanical

20 Young and Burgess: Anterior Posterior Compression Injuries APC-1 APC-2 APC-3 < 2 cm diastasis Anterior SI Joint SS/ST Ligaments Posterior SI Ligaments No cephalad translation

21 Young and Burgess: Lateral Compression Injuries LC-1 LC-2 LC-3 Anterior sacral compression Posterior sacroiliac fracture dislocation Associated contralateral SI joint ER injury

22 Young and Burgess: Vertical Shear Injury Patterns VS Cephalad or postero-cephalad migration Unstable

23 Letournel (Anatomical) Posterior Pelvis Sacrum SI Joint Crescent Iliac Acetabulum Anterior Pelvis Ramus Pubic Symphysis

24 Mechanism of Injury Acute Care Fracture Mechanism Correlates with: Blood Loss Associated Injuries Multisystem Morbidity Mortality

25 Blood Replacement vs Mechanism Lateral Compression 3.6 Combined Mechanical 8.5 Vertical Shear 9.2 AP Compression 14.8 Burgess et al, J Trauma 1990

26 Mortality APCIII 37% APC II 25% VS 25% LCIII 14%

27 ASSOCIATED INJURIES Lateral Compression: Abdominal visceral injury Head injury Few pelvic vascular injuries AP Compression: Urologic injury Hemorrhage/pelvic vascular injury: APC2-10%, APC3-22%

28 Hemodynamic Instability SBP < 90mmHg Unresponsive to fluids/blood Mortality: Shock on admission associated with pelvic fracture is the most reliable predictor of ISS, transfusion requirement and death (40%)

29 Hemodynamic Instability Consider Other Bleeding Sources Intrathoracic / Intraperitoneal Open Fractures / Closed Fractures Retroperitoneal Bleeding Consider other causes of hypotension Cardiogenic Spinal shock Hypothermia Terminal brain injury Correct Coagulopathy

30 Sources of Pelvic Bleeding Fracture Surfaces Pre-Sacral Venous Plexus Local Arterial Injury Major Vessel Injury

31 Hemorrhage - Treatment Laparotomy with direct vessel ligation Laparotomy with retroperitoneal packing Pelvic Binder External Fixation/C-clamp Angiography/Embolization Acute ORIF pelvic ring

32 Decrease pelvic volume (Tamponade) Prevents gross motion, clot disruption External Fixation Improves comfort Reduces cancellous bony bleeding Theories

33 Easy, rapid application Useful in various patterns of injury Can be maintained for extended time External Fixation Advantages

34 Induces additional deformity Poor control of posterior pelvic ring Pin tract infections External Fixation Disadvantages

35 Induces additional deformity Poor control of posterior pelvic ring Pin tract infections External Fixation Disadvantages

36 Posterior External Fixation C-clamp posterior pins ilium rationale: Improved posterior compression

37 Posterior External Fixation

38 Posterior External Fixation

39 Easily Applied during resuscitation Portable Versatile Convert to ExFix, ORIF May hide injuries Skin/Bone Pelvic Binder / Sheet

40 Pelvic Sheet

41 Alone or in combination with anti-shock sheeting/ Ex Fix Particularly useful for vertical shear injuries Prevent ongoing neurologic injury Traction

42 Angiographic Embolization Nonresponders Persistent Hypotension Fluid resuscitation Mechanical Stabilization

43 Open Fractures

44 Open Pelvic Fractures Mortality Literature 4.8% to 50% Hemorrhagic complications Ave 16 U acute resuscitation Ave 29 total transfusion req Brenneman, et al, J Trauma 1997 Septic complications

45 Mortality , Hannover 1899 pelvic fxs, 1029 polytrauma Mortality 17.7% Open fxs 48% to 30% Pohlemann et al, CORR 1994

46 Treatment Algorithm Obtain appropriate radiographs Identify High-risk fracture patterns Hemorrhage Associated Injuries Open fractures Identify High-risk patients Shock

47 Treatment Algorithm Apply binder sheet during initial resuscitation Exclude other sources of bleeding Consider Angiography

48 Thank You